Adi Weintraub
Adi WeintraubMD, Chairman of the Israeli Society for Urogynecology and Pelvic Floor Medicine (ISUG), Head of Urogynecology and Pelvic Floor Services, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of The Negev, Beer Sheva, Israel

The investigation of prolapse recurrence after native tissue repair and identification of risk factors related to recurrence are important clinical and quality control issue. Within this context, surgical anatomy of the vagina and vaginal introitus has gained renewed interest (Mothes et al 2023).

The genital hiatus (GH) is the distance from the midline of the external urethral meatus to the midline of the posterior hymenal ring during maximal valsalva maneuver (Bump et al 1996). There is no standardized cut-off for a normal GH, but in a population-based study of nearly 400 middle-aged women, the mean GH size was 3.43 cm (95% confidence interval [CI] = 3.29–3.57) and median (interquartile range) GH was 3 (3–4) cm (Trowbridge et al 2008).

Three levels of endopelvic fascial support have been described. Level 1 suspends the upper portion of the vagina and the uterine cervix, level 2 supports the middle portion of the vagina and the posterior bladder wall, and level 3 attaches the lower portion of the vagina to the perineal membrane and also includes the urethral suspensory ligaments. The GH is part of the level 3 perineal support ( Haylen et al 2022).

Evidence is accumulating that prolapse development is strongly associated with the size of the GH (Handa et al 2021; Handa et al 2019). Moreover, increased GH was found to be related to risk for prolapse recurrence (Schmidt et al 2022; Vaughan  et al 2018). In a recent study, both preoperative and postoperative enlarged GH correlated with having more surgical failures following apical correction with sacrospinous ligament fixation. A normal postoperative GH size was found to be significantly associated with surgical success (Garcia et al 2022). In another study, correcting GH to <4 cm during prolapse repair was supported to reduce objective long-term failure. Investigators found that early postoperative GH <4 cm was associated with superior long-term objective success, without increasing dyspareunia (Hill et al 2020).

It does appear that with a specific perineal repair at the time of posterior colporrhaphy, the perineal anatomy can be restored in the short term and prevent recurrence in the long-term. However, more research is needed to confirm the findings and to determine the optimal surgical technique for preventing recurrent posterior prolapse.


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Garcia AN, Ulker A, Aserlind A, Timmons D, Medina CA. Enlargement of the genital hiatus is associated with prolapse recurrence in patients undergoing sacrospinous ligament fixation. Int J Gynaecol Obstet. 2022;157:96-101.

Handa VL, Blomquist JL, Carroll M, Roem J, Muñoz A. Longitudinal Changes in the Genital Hiatus Preceding the Development of Pelvic Organ Prolapse. Am J Epidemiol. 2019;188:2196-2201.

Handa VL, Blomquist JL, Carroll MK, Muñoz A. Genital Hiatus Size and the Development of Prolapse Among Parous Women. Female Pelvic Med Reconstr Surg. 2021;27:e448-e452.

Haylen BT, Vu D, Wong A. Surgical anatomy of the vaginal introitus. Neurourol Urodyn. 2022;41:1240-7.

Hill AM, Shatkin-Margolis A, Smith BC, Pauls RN. Associating genital hiatus size with long-term outcomes after apical suspension. Int Urogynecol J. 2020;31:1537-44.

Mothes AR, Raguse I, Kather A, Runnebaum IB. Native-tissue pelvic organ prolapse (POP) repair with perineorrhaphy for level III support results in reduced genital hiatus size and improved quality of life in sexually active and inactive patients. Eur J Obstet Gynecol Reprod Biol. 2023;280:144-9.

Schmidt P, Chen L, DeLancey JO, Swenson CW. Preoperative level II/III MRI measures predicting long-term prolapse recurrence after native tissue repair. Int Urogynecol J. 2022;33:133-41.

Trowbridge ER, Fultz NH, Patel DA, DeLancey JO, Fenner DE. Distribution of pelvic organ support measures in a population-based sample of middle-aged, community-dwelling African American and white women in southeastern Michigan. Am J Obstet Gynecol. 2008;198:548.e1-6.

Vaughan MH, Siddiqui NY, Newcomb LK, Weidner AC, Kawasaki A, Visco AG, et al. Surgical Alteration of Genital Hiatus Size and Anatomic Failure After Vaginal Vault Suspension. Obstet Gynecol. 2018;131:1137-44.